Can Cementing Technique Reduce the Cost of a Primary Total Knee Arthroplasty?

Abstract

Studies on cost containment of total knee arthroplasty (TKA) have generated substantial interest over the past decade. Although multiple studies have evaluated the various intraoperative methods to control cost, no prior study has evaluated the economic impact and the clinical outcome based on amount of bone cement needed for a primary TKA. At a minimum of 3 years follow-up, we observed no difference in implant survivorship or Knee Society scores, but did observe substantial cost savings when one versus two packets of bone cement were used in combination with a hand mixing technique. By eliminating several extra cement mixing products, we achieved an approximately $1,000 cost saving per case with no difference in clinical outcomes at midterm follow-up.

Keywords

TKA - arthroplasty - cement - cost/economic

• References

• 1 National Statistics on all Stays: 2005 Outcomes by Patient and Hospital Characteristics for ICD-9-CM Principal Procedure Code 81.54—Total Knee Replacement; 2005. Available at: http://hcupnet.ahrq.gov/HCUPnet.jsp ; Accessed December 1, 2012
• 2 Lovald ST, Ong KL, Lau EC, Schmier JK, Bozic KJ, Kurtz SM. Mortality, cost, and health outcomes of total knee arthroplasty in Medicare patients. J Arthroplasty 2013; 28 (3) 449-454
• 3 Losina E, Walensky RP, Kessler CL , et al. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med 2009; 169 (12) 1113-1121 , discussion 1121–1122
• 4 Krummenauer F, Wolf C, Günther KP, Kirschner S. Clinical benefit and cost effectiveness of total knee arthroplasty in the older patient. Eur J Med Res 2009; 14: 76-84
• 5 Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg Am 2002; 84-A (3) 348-353
• 6 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467 (10) 2606-2612
• 7 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (4) 780-785
• 8 Naziri Q, Pivec R, Harwin SF , et al. New technologies in knee arthroplasty. Surg Technol Int 2012; 22: 272-284
• 9 Berger RA, Rosenberg AG, Barden RM, Sheinkop MB, Jacobs JJ, Galante JO. Long-term followup of the Miller-Galante total knee replacement. Clin Orthop Relat Res 2001; (388) 58-67
• 10 Buechel Sr FF, Buechel Jr FF, Pappas MJ, Dalessio J. Twenty-year evaluation of the New Jersey LCS Rotating Platform Knee Replacement. J Knee Surg 2002; 15 (2) 84-89
• 11 Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res 1997; (345) 79-86
• 12 Ito J, Koshino T, Okamoto R, Saito T. 15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis. J Arthroplasty 2003; 18 (8) 984-992
• 13 Keating EM, Meding JB, Faris PM, Ritter MA. Long-term followup of nonmodular total knee replacements. Clin Orthop Relat Res 2002; (404) 34-39
• 14 Scuderi GR, Insall JN, Windsor RE, Moran MC. Survivorship of cemented knee replacements. J Bone Joint Surg Br 1989; 71 (5) 798-803
• 15 Bindelglass DF, Cohen JL, Dorr LD. Patellar tilt and subluxation in total knee arthroplasty. Relationship to pain, fixation, and design. Clin Orthop Relat Res 1993; (286) 103-109
• 16 Healy WL, Rana AJ, Iorio R. Hospital economics of primary total knee arthroplasty at a teaching hospital. Clin Orthop Relat Res 2011; 469 (1) 87-94
• 17 Healy WL, Iorio R. Implant selection and cost for total joint arthroplasty: conflict between surgeons and hospitals. Clin Orthop Relat Res 2007; 457 (457) 57-63
• 18 Healy WL, Iorio R, Lemos MJ , et al. Single price/case price purchasing in orthopaedic surgery: experience at the Lahey Clinic. J Bone Joint Surg Am 2000; 82 (5) 607-612
• 19 Healy WL, Iorio R, Richards JA, Lucchesi C. Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment. J Arthroplasty 1998; 13 (5) 504-507
• 20 Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; (248) 13-14
• 21 Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 1989; (248) 9-12
• 22 Annual Financial Data Hospital Chargemasters; 2013. Available at: http://www.oshpd.ca.gov/chargemaster/ ; Accessed April 10, 2013
• 23 Macaulay W, DiGiovanni CW, Restrepo A , et al. Differences in bone-cement porosity by vacuum mixing, centrifugation, and hand mixing. J Arthroplasty 2002; 17 (5) 569-575
• 24 Kopec M, Milbrandt JC, Duellman T, Mangan D, Allan DG. Effect of hand packing versus cement gun pressurization on cement mantle in total knee arthroplasty. Can J Surg 2009; 52 (6) 490-494
• 25 Vanlommel J, Luyckx JP, Labey L, Innocenti B, De Corte R, Bellemans J. Cementing the tibial component in total knee arthroplasty: which technique is the best?. J Arthroplasty 2011; 26 (3) 492-496
• 26 Askew MJ, Steege JW, Lewis JL, Ranieri JR, Wixson RL. Effect of cement pressure and bone strength on polymethylmethacrylate fixation. J Orthop Res 1984; 1 (4) 412-420
• 27 Benjamin JB, Gie GA, Lee AJ, Ling RS, Volz RG. Cementing technique and the effects of bleeding. J Bone Joint Surg Br 1987; 69 (4) 620-624
• 28 Lutz MJ, Pincus PF, Whitehouse SL, Halliday BR. The effect of cement gun and cement syringe use on the tibial cement mantle in total knee arthroplasty. J Arthroplasty 2009; 24 (3) 461-467
• 29 Walker PS, Soudry M, Ewald FC, McVickar H. Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res 1984; (185) 155-164
• 30 Breusch SJ, Norman TL, Schneider U, Reitzel T, Blaha JD, Lukoschek M. Lavage technique in total hip arthroplasty: jet lavage produces better cement penetration than syringe lavage in the proximal femur. J Arthroplasty 2000; 15 (7) 921-927
• 31 Clarius M, Hauck C, Seeger JB, James A, Murray DW, Aldinger PR. Pulsed lavage reduces the incidence of radiolucent lines under the tibial tray of Oxford unicompartmental knee arthroplasty: pulsed lavage versus syringe lavage. Int Orthop 2009; 33 (6) 1585-1590
• 32 Maistrelli GL, Antonelli L, Fornasier V, Mahomed N. Cement penetration with pulsed lavage versus syringe irrigation in total knee arthroplasty. Clin Orthop Relat Res 1995; (312) 261-265
• 33 Schlegel UJ, Siewe J, Delank KS , et al. Pulsed lavage improves fixation strength of cemented tibial components. Int Orthop 2011; 35 (8) 1165-1169
• 34 Cawley DT, Kelly N, McGarry JP, Shannon FJ. Cementing techniques for the tibial component in primary total knee replacement. Bone Joint J 2013; 95-B (3) 295-300
• 35 Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am 2002; 84-A (5) 759-762
• 36 Dunbar MJ. Antibiotic bone cements: their use in routine primary total joint arthroplasty is justified. Orthopedics 2009; 32 (9)
• 37 National Joint Registry for England and Wales, 9th Annual Report; 2012. Available at: http://www.njrcentre.org.uk/njrcentre/default.aspx
• 38 Persson U, Persson M, Malchau H. The economics of preventing revisions in total hip replacement. Acta Orthop Scand 1999; 70 (2) 163-169
• 39 Espehaug B, Engesaeter LB, Vollset SE, Havelin LI, Langeland N. Antibiotic prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip replacements reported to the Norwegian arthroplasty register, 1987 to 1995. J Bone Joint Surg Br 1997; 79 (4) 590-595
• 40 Chiu FY, Lin CF, Chen CM, Lo WH, Chaung TY. Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomised study. J Bone Joint Surg Br 2001; 83 (5) 691-695
• 41 Bourne RB. Prophylactic use of antibiotic bone cement: an emerging standard—in the affirmative. J Arthroplasty 2004; 19 (4) (Suppl. 01) 69-72
• 42 Nijhof MW, Dhert WJ, Fleer A, Vogely HC, Verbout AJ. Prophylaxis of implant-related staphylococcal infections using tobramycin-containing bone cement. J Biomed Mater Res 2000; 52 (4) 754-761
• 43 Josefsson G, Kolmert L. Prophylaxis with systematic antibiotics versus gentamicin bone cement in total hip arthroplasty. A ten-year survey of 1,688 hips. Clin Orthop Relat Res 1993; (292) 210-214
• 44 Hanssen AD. Prophylactic use of antibiotic bone cement: an emerging standard—in opposition. J Arthroplasty 2004; 19 (4) (Suppl. 01) 73-77
• 45 Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 2009; 24 (6, Suppl): 44-47
• 46 Gandhi R, Razak F, Pathy R, Davey JR, Syed K, Mahomed NN. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J Arthroplasty 2009; 24 (7) 1015-1018
• 47 Cui Q, Mihalko WM, Shields JS, Ries M, Saleh KJ. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am 2007; 89 (4) 871-882
• 48 Duncan CP, Masri BA. The role of antibiotic-loaded cement in the treatment of an infection after a hip replacement. Instr Course Lect 1995; 44: 305-313